Preparing for Reform with Technology for Reform with Technology Kate McCarthy Boston, MA ... – Medications including administration instructions ... Build new relationships

©2012 CliftonLarsonAllen LLP1 111

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Preparing for Reform with Technology

Kate McCarthyBoston, MA

Jay PizingerMinneapolis, MN

LSN Annual ConferenceWednesday May 2, 2012

Session 61C

©2012 CliftonLarsonAllen LLP2

What we will discuss

• What is an Electronic Health Record?• The Importance of “Meaningful Use”• How Health Care Reform Pays and Penalizes for

Technology Use• Cost Ranges for Implementation• Strategic Capital Planning and Determination of

Need• Software Selection and Project Management• Examples, Case Study and Questions


EMR v. EHR

• An Electronic Medical Record (EMR) is an electronic copy of a patient chart, designed for simple charting and documentation

• An Electronic Health Record (EHR) is a dynamic system that collects patient data, and when properly installed, can generate sophisticated data

• EHR is more integrated and interoperable if properly designed


EHRs and Meaningful Use

• The Office of the National Coordinator (ONC) for Health Care Information Technology defines meaningful use by provider type– The Certification Commission for Healthcare Information

Technology (CCHIT) is authorized by ONC to Certify Meaningful Use◊ Currently there is NO ONC Meaningful Use Criteria for post-acute

providers◊ All grants available for EHRs for post-acute providers will have a

“Meaningful Use” requirement• Are there grants available in Illinois for post-acute providers?

Source: CCHIT Recommendations of the Long Term & Post Acute Care Advisory Task Force: Certification of LTPAC EHR Technology http://www.cchit.org/sites/all/files/LTPAC%20ATF%20Recommendations%20June%2016%202009%20Final_0.pdf

Presenter

Presentation Notes

Check the State Website for any grants for Tech dollars available.


Per ONC, Meaningful Use Allows Providers to:• Know more about their patients. Information in electronic health

records can be used to coordinate and improve the quality of patient care.

• Make better decisions. With more comprehensive information readily and securely available, clinicians will have the information they need about treatments and conditions – even best practices for patient populations –when making treatment decisions.

• Save money. Electronic health records require an initial investment of time and money. But clinicians who have implemented them have reported reductions in the amount of time spent locating paper files, transcribing and spending time on the phone with labs or pharmacies; more accurate coding; and reductions in reporting burden.


Meaningful Use for LT-PAC Providers• An LT-PAC EHR should:

– Allow for longitudinal tracking of a patient across care settings (CCRC’s, other services, community, acute)

– Be compliant with American Reinvestment and Recovery Act (ARRA) EHR requirements (HL7)◊ Be interoperable◊ Enter, create and manage direct care functions:

• Patient demographics• Clinical health information including:

– Problem lists – Medical History

– Active Diagnoses– Inactive Problems



Meaningful Use for LT-PAC Providers (continued)

• LT-PAC EHRs should document, manage and report:– Advance Directives (documents and care orders)– Allergies and alerts– Capture, query and report compliance with health care quality measures– Clinical decision support – Family and Social History– Functional Status– Medication Lists including medication reconciliation during transitions of

care– Provider order management – Medications including administration instructions– Non-medication Treatments– Setting-specific assessments as required for reimbursement (e.g., MDS for

SNFs/NFs)



But I already have tools that capture this data?

Why do I need to invest in an EHR??

Presenter

Presentation Notes

Payment reform is coming no matter what


Public PolicyCMS Vision for Post-Acute Care

“The person-centered post-acute care system of the future will:– Optimize choice and control of services;

– Ensure that placement decisions are based on patient needs;

– Provide coordinated, high quality care with seamless transitions between settings;

– Reward excellence by reflecting performance on quality measures in payment;

– Recognize the critical role of family care giving; and

– Utilize health information technology.”

Source: CMS Policy Council Document, 9/28/06 “Post-Acute Care Reform Plan; reviewed at MedPAC 1/07


Bundled Payments and the Building Blocks of Health Reform

Access to CareInformation

*Quality and EHR

Payment Reductions

Care Reform*Wellness *Prevention

*Chronic care management

Payment Reductions

Payment Reform: Reward and

increase value

Presenter

Presentation Notes

Regardless of whether we are talking about federal or state reform, or public vs. private pay, these themes apply. Not only will reform change the way we pay for care, how we deliver care and how we organize care but it will also change consumer expectations – increasing transparency around quality, ability of providers to share data/EHRs, patient-centered care, cost-effective services delivered at most appropriate site of service. Could it mean new competitors? SNF v. TCU v. sub-acute; AL v. home v. SNF?


New Business ModelsPutting the Patient First

Patient CenteredAccountable Care that is Patient Centric will lead to improved clinical pathways, efficiencies and outcomes.


New Payment ModelsSpectrum of Payment Options

Increasing Risk & Uncertainty, Enhanced Collaboration & Communication, Increasingly Complex Metrics and Business Practices


New Payment ModelsValue Based Reimbursement – CMS’s Goals1. Improve clinical quality2. Address problems of underuse, overuse, and misuse of services3. Encourage patient centered care4. Reduce adverse events & improve patient safety5. Avoid unnecessary costs 6. Stimulate investments in infrastructure & redesign care processes that

serve clients across an episode &/or the continuum7. Make performance results transparent8. Avoid creating additional & reduce existing disparities in health care

The incentives are designed to reward both improvement and attainment by spreading the payments broadly amongst providers and to encourage improvement by all, not picking winners or losers.

Source: “Report to Congress: Plan to Implement a Medicare Hospital Value-Based Purchasing Program”, CMS, US Dept of Health & Human Services, 11/21/07, pages 23. & 27


Okay then!

How much will this cost me?What will implementation demand of

my staff?


Average Cost Per Facility by EHR Type

CIO EMR Cost Study January 2011 Implementing and Operating Electronic Medical Records in the Long Term & Post Acute Care Environment

Presenter

Presentation Notes

People costs are lower on SaaS and Hosted but depending on location you could pay the same or more due to bandwidth issues and costs. Software as a Service – Software delivery model that is on demand. Hosted centrally. Regular updates occur automatically. The difference is a Service Element involved on the SaaS model. Hosted is a product you bought but no server at all. SaaS is also a product in the cloud but all services are included in one price. All-scripts is SaaS, GE Centricity is SaaS. SaaS you pay a little more than Hosted but they are pretty consistent in pricing. Year 4 increase is due to updates, hardware, software, etc.


What to Expect

• Cost of and outcome of implementation is highly dependant on the quality of the implementation

– Invest in dedicated staff and training to ensure ongoing success

• Costs to anticipate (estimates from client experience, many imbedded in

CIO report estimates):– Software selection: $10,000-$15,000– Implementation plan: $3,000-$5,000– Vendor install and phone implement: $8,000-$10,00– Consultant to Internally Lead Clinical: $30,000-$40,000– Consultant to internally Lead AR install $15,000-$20,000– Increases hardware on desk: 10-15 added PCS $20,000-$30,000– Enhance internet, wireless and network capability: $35,000-$50,000– Electronic documentation kiosks: $5,000-$20,000– Staff training: $5,000 (excludes opportunity cost)– Dedicated internal champion: full-time or .75 $50,000-$70,000


Okay then!

This isn’t in my budget. How can I pay for it?


Strategies to Identify Return on Investment

• Grants are currently being tested in LT-PAC settings across the US– Future access to new grants will be dependant on having

an installed EHR that meets some standard Meaningful Use Criteria

• Access to Value Based Purchasing arrangements (eg., ACOs, Bundled Payments) will depend on your ability to demonstrate meaningful and interoperable use of Health Care Information Technology (HIT)

• Other sources?


Strategic Capital Planning

• Put together a strategic capital plan that covers a span of 3-years– Make sure it is a “soup-to-nuts” plan

• Questions to answer during the process:– Funding Expansion - Operations &/or Capital?– Cost of Operations - Benchmarks & Ratios?– Revenue Enhancement – Reimbursement, Payer Mix?– Financial Feasibility – Diversification Impact?– Market Studies – Needs & New services?– Strategic Capital Planning – Long term vs. Short term?


Preparing for Change …

Key strategies

Decide: lead, follow, resist

Prepare to assume risk

Use technology betterAlign providers interests

Connect quality to value

Build new relationships

Presenter

Presentation Notes

Change is hard, however… we understand the doing things differently does not happen over night. As an experiment, cross your arms. Now, cross them the other way. Doesn’t feel natural, does it? Matter of fact, it feels quite uncomfortable and absent any reason for change, we’ll very quickly go back to doing it the same way. Sustainable change is nearly impossible without significant planning, communication and reinforcement… and discipline. But we have time to adapt… we suggest you start preparing now. Key strategies for senior living providers: 1. Bend the cost curve – lower costs and increase effectiveness 2. Understand and capitalize on strengths – Create an understanding of existing patient care delivery patterns; Identify and implement best practices and strategies by diagnoses 3. Use technology better – Develop electronic health exchange, monitoring tools and communication vehicles 4. Focus on patient, not process – Determine practices for patient-centered care and patient engagement approaches 5. Connect Quality to Value – Define a financially savvy path transitioning to value based/gain-sharing payments 6. Build new relationships – Develop relationships at the organizational level, not just referral level Excerpt from Richter Blog – 10/18/10 As you might expect, we have been asked to make presentations about health care reform in many audiences – both inside and outside of the health care industry. We discuss the varying implications for providers, employers and individuals – many of which don’t take effect for years and most of which relate to concepts that will need rules and regulations to support implementation. At the conclusion of these presentations, when heads are spinning and thoughts are flying, we are often asked a simple question, “what do we do now?” We’ve boiled it down to six key strategies… strategies that will apply whether the current payment models survive or not. The strategies are based on practical and sound business principles – addressing the issues that won’t go away, cost that is too high and quality that is not commensurate with the costs. Bend the cost curve, not just control costs – This means "do things differently!" An example: We are assisting a Texas facility (actually 32 facilities) with implementation of Lean Manufacturing Principles (official definition of doing it differently: The continual pursuit of delivering value for customers in the least waste way). Very simply, we are trying to help them remove the waste (waiting time, transition time, paperwork... anything not resident related). One recent Kaizen event (a tool used to map, modify and implement processes) resulted in "liberation of 185 of the CNA time by reducing time spent walking and searching for supplies... facility chose to eliminate 3 FTEs and use remainder of time to improve patient experience. This facility is convinced it has "only scratched the surface" of opportunity. The point is... don't let regulations define your operations... do it differently! Understanding and capitalizing on strengths – we must create an understanding of existing patient care delivery patterns while identifying and implementing best practices and strategies by diagnosis Think differently about technology. Today we use technology to deliver high tech medical procedures, manage information and, perhaps, monitor patients inside / outside our facility walls. In the future we must use technology to exchange information with other providers in continuum (administrative burden) and to improve productivity (so clinical staff can focus on patient, not process). Focus on patient, not process – We must develop practices for patient centered care that engages the patient (and family if necessary) in their personalized plan. Focus on value, not quality alone – Quality today is largely a quantitative effort driven by checklists and regulators. Value should be best patient experience focused on delivering results at lowest overall cost (not just what happens inside our facility / service offerings). This is largely a mindset shift that will produce better overall results... leading to longer term sustainable profitability... Develop different relationships - today, referrals drive business; in the future, organizational relationships and alliances will drive growth. This means that relationships must eminate from the C-Suite.


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Software Selection and Project Management

EHR Implementation or Total Replacement Approach


Objectives:

• Define the Needs of the Clinical and Business Office team

• Outline Software Request For Proposal and Selection Approach

• Describe Project Management Options


Define the Needs

• What Are The Needs?– Outdated current system– Requirement, compliance or regulatory– Add-on to existing

• Discuss Software Selection Process Approaches

• Discuss Project Management Options

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Approach To “Meeting The Needs”

• Understand the Scope of Software Selection;• Discovery of Current Reports, Processes and Procedures;• What Do We Want to Improve?;• Develop Weighted Assessment of the Needs;• Identify Fully Integrated (Clinical, G/L, reporting, etc.) and Best of Breed

Vendors (components with integration);• Develop and Deliver Request for Proposal to Targeted Vendors;• Schedule Initial and In-Depth Product Demonstrations;• Focus on 1-2 Finalists Based on Pre-Defined Criteria;• Check References on Product and Product Support (look externally for

these as well);• Identify All Operating and Capital Costs to Acquire and Implement

Software; and• Identify Qualified Products.


Project Management - TeamTeam members - Clinical• Administrator• Director of Nursing• Assistant Director of Nursing• MDS Coordinator• Staff Development• Nursing Unit Leaders• Lead CNAs

Team members – Financial• CFO• Controller• Assistant Controller• Accounting Manager• Billing Manager and staff• Accounts Payable Supervisor

Team members –Administration• CEO/Executive Director• Director of Information Technology (IT)• IT Communications staff• IT Hardware Support• External Consultants


Project Management - Overall Overall:• Identify project champion(s) who is responsible for all phases of project

management and may be supported by external resources.• Project champion(s) will likely work directly in clinical and/or business

office and be technology savvy. Information Technology (IT) serves as support or advisory to the process.

• Project champion(s) will work with campus leadership to ensure the project is moving at the proper pace. Remove any training or implementation barriers.

• Jointly design a roll-out plan that staff can commit to.


Project Management - Clinical

Clinical: • Provide project leadership that will work closely with the

clinical leadership and implementation team to tailor the EHR and Point-of-Care (POC optional).

• Initiate clinical discovery meetings to define current processes and practices.

• Work closely with administrative and clinical leadership team to define and prioritize the most important EHR elements; take the best of current clinical practices, and supplement them with the benefits and features of the new clinical and billing software.


Project Management – Clinical (con’t)

Clinical: • Project champion will work with the campus administrator

and DON to position the clinical team for success. • Champion works with clinical leadership to ensure they

understands the importance of the daily “homework” to the timely completion of the implementation.

It is important to understand the complex interaction of the clinical software functions and its impact on the billing system and reimbursement.


Project Management - Financial

Financial: • Provide project leadership that will work closely with the

business office leadership and implementation team to tailor the general ledger, financial reporting, billing and accounts payable.

• Initiate business office discovery meetings to define current processes and practices.

• Work closely with administrative and business office leadership team to define and prioritize the most important data elements; take the best of current financial practices, and supplement them with the benefits and features of the new financial and billing software.


Project Management – Financial (con’t)

Financial: • Project champion (could be controller) will work with the

chief financial officer and controller to position the clinical team for success.

• Champion works with financial leadership to ensure they understands the importance of the daily “homework” to the timely completion of the implementation.

It is important to understand the complex interaction of the clinical and billing software functions and its impact on reimbursement.


Sample Work Plan

• Phase I: Define best practices and prioritize Billing/AR, EHR and POC (optional) set up options from a clinical perspective;

• Phase II: Tailor the software installation to meet the needs as defined in Phase I through coordination with the vendor implementation team and site leadership;

• Phase III: Design reports and dashboards that best meet the needs of corporate, business office, site management and medical staff;

• Phase IV: Train and supervise clinical staff (including the medical staff) and billing staff on processes and procedures; and

• Phase V: Evaluate and enhance ADL tracking, medical records and documentation practices to improve revenue realization.


Training and Follow-Up

• Training component is necessary no matter what– External– Internal– On-going

• Training can be the difference between success and failure!

• A best practice– Global training for all – Know the fundamentals– Monitored training (small groups or on-line)– On-Going (quarterly or regular)– Performance metrics reviewed for any concerns or opportunities

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References

• The Certification Commission for Healthcare Information Technology (CCHIT)– www.cchit.org

• Health Information Management Systems Society (HIMSS)– www.himss.org

• LeadingAge– www.leadingage.org

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Thank you!Kate McCarthySenior ConsultantCliftonLarsonAllen, [email protected]

Jay PizingerConsultant ManagerCliftonLarsonAllen, [email protected]

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Preparing for Reform with Technology for Reform with Technology Kate McCarthy Boston, MA ... – Medications including administration instructions ... Build new relationships